Sunday, July 31, 2011

The Start of Audition Rotations

Let the audition rotations begin. Catching the red eye flight from Las Vegas to Miami was not exactly my idea of fun. Nonetheless, I arrived safely and got a sneak peak at where I will be spending the next month. Literally feet from the water, Mt. Sinai Medical Center serves Miami Beach meeting numerous medical needs.

Beach-side Medicine

I was amazed at the number of memorial wings, buildings and structures. This hospital has a long history of providing health care in the community which was demonstrated by the banner at the front entrance sharing the recent news that it provides the best care in geriatrics. This comes as no surprise since the population of retirees is so saturated here. In my brief exploration of the surroundings, however, I did not see too many seniors bathing in the sun and shopping around town. Perhaps I was not on the right side of town. So now I am curious as to who the hospital patient population will be; international tourists, retired seniors or partying youth.

Every hospital tends to have a unique population set. Some see greater numbers of indigent, immigrants, aged or affluent people. Testing the waters now as a medical student will help me when the time comes to make a residency rank list. Knowing what a program has to offer both in academics and patient presentation can have a significant impact on the education to be received. Fortunately, the programs that are weak in one part of the population often send residents to other facilities to get the exposure needed. Until I actually start my shifts, I suppose I will have to remain in suspense and get used to the humidity we rarely get in the desert. 

Question of the Week
A mother brings in her 10 month old child after what she thinks was a seizure. She reports that he was premature and has a history of broken ribs at 6 months of age. On exam you notice his hair to be steel colored and brittle. He appears very malnourished and small for his age. You correctly diagnose him with Menkes disease which has a deficiency of which of the following?

A. Copper
B. Biotin
C. Zinc
D. Niacin
E. Pyridoxine

Answer & Explanation

Sunday, July 24, 2011

The Doctor Behind the Curtain

As the month comes quickly to a close, I reflect on the time I had in the operating room that was definitely an enjoyable experience. At first glance it looks overwhelming, but in time the buttons and monitors have started to make sense. It is no wonder that there is a dedicated individual at the head of any operating table managing a patient's life.

Sweet Dreams

There is much more to anesthesia than putting tubes here and wires there. As the photo demonstrates, there is one tower for monitoring the patient while providing life support and another for the medications that assist in that effort. Poles for fluid resuscitation, suctioning for secretions and gizmos for I don't know what that keep a patient happily asleep. It is amazing that so many tools, gadgets and devices can be crammed into such a small space and have such a large impact. There is barely enough room back there for the physician let alone a student to participate and learn. Despite the lack of space, the attendings continually let me interact with intubations, monitoring and interventional  procedures to get the full experience. These docs run a great one-man show and are so full of knowledge that I often could not keep up.

This niche in medicine will apparently have a 15,000 physician shortage in the year 2020. I hear medical students clamoring to get on board and it seems that the doors may be opening for them. From the physicians who tout the profession, they share their opinion as though it is medicine's best kept secret. They manage only one patient at a time who they rarely seen again, earn a significantly comfortable salary, and between the induction/emergence phases of anesthesia have few complications. On more than one occasion I have noted the relaxed and stressless demeanor of these specialists to be common for the profession. But when patients are in distress, these doctors are collected enough to help carry a patient through more often than not. It has been a good month with plenty to learn.

Question of the Week
A 30 year old male presents to the emergency department with muscle rigidity and dyskinesias. You notice he is mute, incontinent, in and out of consciousness, and febrile. He is diagnosed with neuroleptic malignant syndrome. Which of the following would be least useful in the treatment of this patient's symptoms?

A. Admission to the hospital
B. Replenishment of IV fluids
C. Administration of bromocriptine
D. Administration of dantrolene sodium
E. Administration of haloperidol

Answer & Explanation

Sunday, July 17, 2011

Being Prepared

While sitting at my desk peacefully studying for the upcoming board exam, I heard the rubber of tires sliding across pavement punctuated by an unmistakable thud. Someone hit something and it was right outside my door. I jumped into action having no idea what I would find, and relying on the limited medical training I already had. 

Responding Empty-Handed but Full-Headed

It didn't take long to realize that the young man driving was distraught by the apologies he was spewing at the man who lay on the ground in pain and shock. To make things worse, the man's dog was only feet away showing no signs of life. With no traffic around, I made my way to the middle of the intersection as a first responder to assess the situation. Two patients: both alive, one clearly injured and the other in a state of hysteria. The police arrived shortly thereafter to control traffic, call for medics and calm the driver. My training took over and after a quick introduction to the injured man I began a rapid trauma assessment looking for injuries from head to toe. Once it was determined that there were no obvious life threats, I focused on those things that he could identify as bothersome. With no equipment to dress his wounds, I started taking a medical history to keep his mind off of the loss of his dog and to provide the medical crew when they arrived. It was sad to see the aftermath of an unintended event and I can only imagine how it will change their lives forever.

Moments such as this benefit from the "what if" game I have played so often. Never knowing when I will have to use my training keeps me in a constant state of preparedness. It's an awful thing when people become injured or ill, but knowing how to help in that time of need is a comforting feeling. A feeling that I would rather have than that of helplessness when it matters most. I will likely never hear from the individuals involved in this particular incident, but the satisfaction of being prepared was fulfilling enough to know that I am slowly learning that which I need to and understanding how to apply it in practical situations. It was another affirmation that my pursuit of emergency medicine is not in vain.

Question of the Week
All of the following are surgical emergencies EXCEPT:

A. A tense swollen foot that was run over by a car. There are no fractures but the patient is in severe pain and has pain with passive toe extension.
B. A tibia fracture with a small pinhole in the skin over the fracture site that drains blood containing fat droplets.
C. A knee dislocation with no fractures, but a cold pulseless foot.
D. A supracondylar humerus fracture in a ten-year-old with decreased sensation in the median nerve distribution.
E. A distal radius fracture in a five-year-old with obvious visual deformity and intra-articular displacement.

Answer & Explanation

Sunday, July 10, 2011

The Art of an Operating Room

For whatever reason, I missed out on a general surgery rotation in my third year of medical school. It was replaced by random surgical specialties which were educational, but did not cover the basics of surgery. Now that I am rotating with anesthesia, I am seeing a larger variety of surgery than I could have imagined.

Effects of Cold Steel

In only a week's time I have observed surgeries from head to toe and everything in between. Some abbreviated and others extensive. All bring their own sense of fascination as they are usually a definitive treatment for the patient's particular condition. On numerous occasions I was able to witness cases that I thought were simply for the textbooks; in other words, those that rarely make their way into the operating room. Skin grafting, thyroglossal duct cyst removal, gangrenous cholecystectomy, thoracotomy, colectomy, craniotomy to name some that have stood out. After meeting up with the anesthesiologist and putting the patient to sleep, I stick around if the case has some educational appeal. Since I never had the traditional general surgery rotation, I am doubling up this month to get the most possible from this experience.

Life in the O.R. is an array of medical art. Everyone has a role and moves to fill it with precision. The colors of contrasting sterile blue against blood red seem to glow under the lights while everyone mysteriously peers over their masks. Instruments shimmer in cleanliness as they move to and from the operating field. The sounds of monitors keeping pace, instruments doing their job and personnel collaborating fills the silence creating an ambient effect. In concert everyone works together to see that the patient has a positive outcome. It's a beautiful place to observe and learn, it's a place where things get done. 

Question of the Week
A febrile 12-year-old child presents with severe right lower quadrant
pain that is interpreted by the attending physician as acute appendicitis.
The patient has also been complaining of joint pain. At laparotomy, the
surgeon notes that the appendix is normal; however, the mesenteric lymph
nodes are markedly enlarged and contain focal areas of microabscess
formation on cut section. This patient is most likely

A. An asthmatic
B. Deficient in C1 esterase inhibitor activity
C. HLA-B27 positive
D. Leukopenic
E. Serologically positive for toxoplasmosis

Answer & Explanation

Sunday, July 3, 2011

Anesthesia 101

After introducing myself to the anesthesiologist I would be working with for the day he quipped, "I'm not an intubation monkey, you are going to learn something this month." With many years under his belt and all the students he has seen, I had a feeling he was speaking from experience. He taught and I learned from the best writing space available, his knee.

Moving Forward

Some have said that fourth year is the apology for the first three years of medical school. We get more freedom to explore our interests and roam about the country finding residency programs worth our time. At last we get a little autonomy and it was for this reason I chose to do anesthesia early in my fourth year. Since I plan to go into emergency medicine, it will help me with sedations, analgesia, medications and airway management via intubations. (Apparently, Dr. Anesthesiologist saw right through that one.) Fortunately, I had no problem with the first tube of the day and we were rather productive as far as teacher and student are concerned.

It seems that for the most part, anesthesia is a calm environment at the head of the table hidden behind the sterile drapes. It consists of mostly monitors, charting and pharmacologic management of the surgical patient. On rare occasions things get a little hairy and I was fortunate enough to experience one such event on the first day. Fortunate because it brings a new understanding to the profession. The patient was dying and the anxious surgeon was eager to start the case. But before anything could happen the patient needed to be resuscitated or the surgery would be futile. Tensions ran high for a short time, but through focused efforts the patient responded to treatment and the surgery was performed as planned with no complications.

Every rotation seems to have significant learning potential and I doubt this one will be any different. I look forward to a busy and productive fourth year. It also happens to be my last year as a tuition paying student which is quite a happy thought.

Question of the Week
A patient becomes cyanotic, has profuse sweating, an unstable blood pressure, and a temperature of 106°F two to three minutes after induction of general anesthesia with halothane. Appropriate intervention would consist of respiratory support and the administration of which of the following?

A. Succinylcholine
B. Dantrolene
C. Acetominophen
D. Hydrocortisone
E. Epinephrine

Answer & Explanation

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